<p> BOARD CERTIFICATION EXEMPTION REQUEST</p><p>Instructions: 1. Department Chair to Complete Section “A” and submit to Vice Chancellor (MC 0602) 2. Vice Chancellor to Complete Section “B” and return to Department Chair 3. Copy to Medical Staff Administration (MC 8821)</p><p>SECTION A</p><p>Exemption Requested for (Print Physician Name): </p><p>Department: Mail Code: </p><p>Department Chair Signature: Date: </p><p>I am requesting an exemption for the above named physician in accordance with UCSD Medical Staff Policy 18: Board Certification.</p><p>Rationale for board certification exemption request (Check  One):</p><p> The physician listed above is foreign trained, which precludes certification by an American Board.</p><p> The physician listed above is no longer board eligible, but has demonstrated ongoing clinical activity without quality concerns. </p><p>Submit to the Vice Chancellor, Health Sciences (MC 0602)</p><p>======</p><p>SECTION B</p><p> Approved; Permanent exemption</p><p> Approved; Time limited exemption. Expiration Date: </p><p> Denied</p><p>Signature: Date: David Brenner, M.D.</p><p>Attachment: MSP 18 – Board Certification MEDICAL STAFF POLICY & PROCEDURE</p><p>Effective Date: Review/Revised: Policy No. 07/16/2009 MSP – 018 Page 2 of 3</p><p>TITLE: Board Certification</p><p>REFERENCE: TJC MS01.01.01.8; Medical Staff Bylaws Article 11</p><p>The requirement for physicians to achieve board certification is intended to maintain the high professional standards of UCSD medical staff, and to ensure consistency throughout departments. Department Chairs are responsible for compliance with this policy.</p><p>Newly Appointed Medical Staff Members - Newly appointed physician members of the medical staff shall obtain board certification by the appropriate credentialing board of the American Board of Medical Specialties (ABMS), or the American Osteopathic Association (AOA), or by the American Board of Oral and Maxillofacial Surgery within five (5) years of their initial appointment. </p><p>Current Medical Staff Members – Active board certification in primary field or subspecialty, as appropriate to their delineation of privileges, is required for physicians with active medical staff privileges. For individuals appointed before Sept 1, 2009, who have not achieved board certification, certification should be achieved by August 31, 2014. </p><p>Exemptions: Physicians with sufficient clinical training and experience may apply for an exemption to the board certification requirement. Indications for exemptions include individuals with foreign training which precludes certification by an American Board, or individuals who have allowed board certification to lapse and are no longer board eligible but have demonstrated ongoing clinical activity without quality concerns. a. A written request for an exemption, which includes the basis for exemption, must be made to the Department Chair. b. The Department Chair, after review of the request, may appeal in writing to the Vice Chancellor, Health Sciences for an exemption. c. The Vice Chancellor will evaluate the request and determine if an exemption is to be granted on a permanent or time limited basis. </p><p>Failure to maintain active board certification will be considered as possible grounds for non-reappointment or termination of medical staff privileges, unless an exemption has been granted by the Vice Chancellor, Health Sciences.</p><p>Dentists, podiatrists, psychologists and members of the Courtesy Teaching/Research Medical Staff are exempt from the Board Certification requirement.</p><p>Policy: Reappointment – Medical Staff APPROVALS: Approved: Revised: Medical Staff Services Office 06/29/09 07/06/09 Credentials Committee 07/01/09 Medical Staff Executive Committee 07/16/09 CEO, UCSD Medical Center, representing the Governing Body 07/16/09 Page 3 of 3 Policy: MSP - 018 TITLE: Board Certification</p>